The effectiveness of motivational interviewing in improving health outcomes in adults with type 2 diabetes

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1 Available online at Procedia Social and Behavioral Sciences 5 (2010) WCPCG-2010 The effectiveness of motivational interviewing in improving health outcomes in adults with type 2 diabetes Hamid Pourisharif a F*F, Jalil Babapour a, Reza Zamani b, Mohamad A. Besharat b, Amir H. Mehryar b, Asadolah Rajab b a Department of Psychology, Tabriz University,Tabriz, Iran b Department of Psychology, Tehran University,Tehran, Iran Received January 5, 2010; revised February 2, 2010; accepted March 22, 2010 Abstract Diabetes is one of the most serious, threatening, developing, and costly health problems. This disease can influence the psychological and especially physical dimensions of people. The aim of current study was investigation of the effects of group Motivational Interviewing (MI) and Cognitive Behavioral Group Training (CBGT) in improving physical health outcomes among adults with diabetes type 2. Ninety- three Patients with type 2 diabetes were selected from Iranian Diabetes Society and Institute of Endocrinology and Metabolism. The participants were randomly allocated to the MI group, CBGT group, and the control group and were tested before and after intervention. Each of interventions consisted of four 90 minutes group sessions. The findings showed that in the MI and CBGT groups, mean of BMI was significantly lower than control group. Also, it was found that, in the MI, the mean of HbA1c was significantly lower than CBGT intervention group. The results indicated that in helping adults with type 2 diabetes, CBGT and MI in group format may be useful interventions to improve their weight loss, and MI may be a useful intervention to improve their glycemic control than CBGT. Theoretical and practical implications of results are discussed Elsevier Ltd. Open access under CC BY-NC-ND license. Keywords: Type 2 diabetes, motivational interviewing, cognitive behavioral group training, physical health. 1. Introduction Diabetes is prevalent in all over the world. Regarding the cause determination, there are 2 different types of diabetes: type 1, and type 2. Diabetes Type 1 was known former as insulin dependent or juvenile onset and it s being diagnosed mostly among children, teenagers, and youth. Type 2 diabetes which is approximately widespread among 90% of diabetic patients is called noninsulin dependent (Cox, Gonder, Frederick, and Clark 2002). Universal prevalence of diabetes in the year 2000 has been estimated about 2.8%, i.e. 171 million people were under the influence of this disease. It s being anticipated that in the year 2030 this number will be increased to 366 million people (Wild, Roglic, Green, Sicree, and King 2004). It seems that 14 to 23% of Iranian people who are more than * Hamid Poursharifi. Tel.: ; fax: address: poursharifi_h@yahoo.com Published by Elsevier Ltd. doi: /j.sbspro Open access under CC BY-NC-ND license.

2 Hamid Pourisharif et al. / Procedia Social and Behavioral Sciences 5 (2010) years old are under the effects of diabetes or have IGT. In Iran, type 2 diabetes has allocated 90 to 95% of these items to itself (Larijani, Zahedi, & Aghakhani, 2003). There is a close relation between weight and diabetes. In 1985 the World Health Organization (WHO) announced obesity as the only serious and controllable risk factor of type 2 diabetes (World Health Organization, 1985). It seems that increase in the prevalence of type 2 diabetes has a great coincidence with the Body Mass Index (BMI), and the prevalence of type2 diabetes is more observable in a society with high rate of obesity (Svendsen, 2003). Beside, diabetes has connection with lifestyle, like sport and nutrition. The alteration of these behaviors has been hard and needs a high degree of effort, impulse and also time. Furthermore the hesitation about making all these changes is another widespread difficulty (Rollnick, Heather and Bell, 1992). The MI is one of the interventions which seem to be effective in increasing the degree of patients' adherence. MI has been found through Miller's experience in treatment of Alcoholic people, and has been completed by Miller and Rollnick (Miller and Rollnick, 1991, 2002). MI's principles are express empathy, develop discrepancy, avoid argumentation, roll with resistance and support self-efficacy (Miller & Rollnick, 2002). According Rubak, Sandbaek, Lauritzen and Christensen (2005) the MI average short-term between-group effect size was One of the first researches related with the effectiveness of MI on diabetic patients is the influence of MI on the effectiveness of their following behavioral weight controlling program of which has been done on healthy and obese women who are affected by Non-Insulin Dependent Diabetes Mellitus (NIDDM) (Smith, Heckemeyer, Kratt, & Mason, 1997). It was concluded that adding a motivational interviewing component to standard behavioral treatment for obese women with NIDDM would significantly increase client adherence to the program and its recommendations, and their glucose control. A similar and a very up to date research has been done by Smith, Dilillo, Bursac,Gore and Green (2007). In this controlled and accidental clinical effort all participants (217 people) received the obesity treatments for 18 months and allotted randomized to individual MI or attention controlling sessions (total 5 sessions) as a complimentary weight controlling program. It seems that the use of MI in weight loss of type 2 diabetic patients has not been done as an independent intervention, but it was used as an additional intervention on a weight loss program. First question is that does the use of MI in a group form with the purpose of increasing the motivation and making some alterations in their nutrition and body activity help diabetic patients in weight loss and the control of blood sugar or not? For eliminating the psychological distress, the cognitive-behavioral interventions can be used. One of these interventions is the Cognitive-Behavioral Group Training (CBGT) which has been essayed by Snoeck, Nicols, Ven and Lubach (1999) for type 1 diabetes and has been adjusted by researcher (Poursharify, 2007) for type 2 diabetes. The CBGT helps diabetes to follow their diets and control the rate of their blood sugar to enhance their psychical health. CBGT has been compiled on the basis of Cognitive-Behavioral Therapy (CBT) principles, and Rational- Emotional Therapy (RET) (Snoeck et al., 1999). Cognitive-Behavioral interventions have been done in different methods on various patients, but the studies of the impacts of CBGT on diabetes have been done only on type 1 diabetes (for example, Esnock and his colleagues, 2001). Although the CBGT has not been done on people with type 2 diabetes, but the cognitive-behavioral interventions has been done on type 2 diabetes (Welschen, et al., 2007). Also a background study shows that CBGT has not been used as a way for weight loss in any researches. Second question is that while considering the nature of this intervention about omitting the psychological distress, can the CBGT lead to the weight loss and the control of blood sugar in diabetic people? The present research has been done for answering these questions. 2. Materials and methods 2.1. Sample Population involved type 2 diabetic patients (non-insulin dependent), literate (at least able to read and write) who were between 30 to 75 years old, and were being considered as the members of the Iranian Diabetic Association, and the metabolism institute of Iranian medical-science university. Patients were chosen from this population which had been diagnosed as patients 12 month ago. Patients which received interventions from other training institutes,

3 1582 Hamid Pourisharif et al. / Procedia Social and Behavioral Sciences 5 (2010) which were illiterate, or which had some serious kinds of health problem unless diabetes, were excluded. Considering the inclusion and exclusion criteria, 93 diabetic patients were chosen Instruments Body Mass Index (BMI): It is calculated by body weight over length square. Score of BMI 18.5 to 25 is normal (Healthy), 25 to 30 is overweighed, and more than 30 is being considered as obese (Bosy-Westphal, et al. 2005). Glycosylated Hemoglobin (HbA1c): HbA1c or hemoglobin AIC is an index to control diabetes. Hemoglobin AIC shows the amount of the average level of blood sugar during 8-12 weeks. The normal amount of glycosylated hemoglobin is 4-5.9%. Diabetics have a high degree of HbAlC (Larsen, Horder, & Mogensen, 1990) Intervention The administration of these two interventions (MI and CBGT) completed in 4 sessions, each 90 minutes. The first test or pretest done before the start of intervention and the second test or post test completed immediately 9 weeks after the last session of intervention. Also the design of research was randomized clinical trial which was done through pretest-posttest with control group Data analysis Data were analyzed by SPSS-15. Kolmogorov-Smirnov tested normality, and for investigation of primarily differences between groups, Kruskal-Wallis test was done. Using MANOVA final analysis was performed. 3. Result On the basis of research purpose, three questions being examined. The first was that, in the individuals with type 2 diabetes, does the group MI improve their physical health indexes? The results are available in the tables 1. According this table, MI significantly improved the BMI (F=3.43, p=0.07). UTable 1. Mean and standard deviation of health indexes in MI and control groups Health Indexes Groups N M SD F BMI Control Group (Posttest - Pretest) MI Group HbA1c Control Group (Posttest - Pretest) MI Group Second research question stated that "Does the CBGT improve physical health index in patients with type 2 diabetes?" The results are available in the tables 2. According this table, CBGT significantly improved the BMI (F=4.65, p=0.04). UTable 2. Mean and standard deviation of health indexes in CBGT and control groups Health Indexes Groups n M SD F BMI Control Group (Posttest - Pretest) CBGT Group HbA1c Control Group (Posttest - Pretest) CBGT Group

4 Hamid Pourisharif et al. / Procedia Social and Behavioral Sciences 5 (2010) Third research question expresses that "Does the effects of MI and CBGT are different on physical health indexes of people with type 2 diabetes?" The results are available in the tables 3. According this table, MI than CBGT significantly improved the BMI (F=4.05, p=0.052). UTable 3. Mean and standard deviation of health indexes in MI and CBGT groups Health Indexes Groups n M SD F BMI MI Group (Posttest - Pretest) CBGT Group HbA1c MI Group (Posttest - Pretest) CBGT Group Discussion and Conclusion Research results show that MI and CBGT each as a separate intervention can improve the BMI, and MI has a better than CBGT impact on HbA1c. The decrease in BMI is one of the fields which show the effect of MI in this research. Some other researchers showed the effects of MI on weight loss (Smith et al., 2007). It seems that the finding of this research is unique, because other researchers have done their studying in the form of additional on interventions. Although, the change of glycosylated hemoglobin has been desirable, but no meaningful difference gained. The results of Rubak et al. (2005) also show that the MI effect on HbAlC was not meaningful. The question is that with the help of which mediator variable, MI and CBGT showed their effect on BMI. Glasgow, et al. (1989) suggested that self-efficacy, outcome expectancies and social support are the predictors of self-care behavior in diabetics. It seems that MI increase of self-efficacy and administrating of MI in group form, acts as a source of social support. Self-efficacy was known as a major variable in long-term control of blood sugar and self-care behaviors (e.g. Aljasem, Peyrot, Wissow, and Rubin, 2001; Ott, Greening, Palardy, and Holderby, 2000; Williames and Bond, 2002).According to this one can recognize the effectiveness of MI through a change in self-efficacy. In this research, diabetes history was as a control variable. The control of diabetes history is a meaningful factor in the studying of the effectiveness of MI. Because, the role of sport is very fundamental in BMI and diabetic people with different history of diabetes, differently do spent. In present research there were some limitations like so many other researches. Unlike the expectancy, some of the participants had a different level of readiness for change. This could affect the outcomes of MI as it s more effective on those who are in lower levels of readiness for change. And some had a good control over their blood sugar and were far from wrong beliefs, which is so important in the results of CBGT. So it s being suggested that the election done from those who are in the lower levels of change for MI and those who have inappropriate control over sugar for CBGT. Psychological interventions can be affect diabetes controllers in three ways. The first thing is to help their patients to accept their disease. Second is to make them increase the self-care and self-efficacy behaviors, and third is to eliminate psychological distress which makes the act of controlling the disease much harder (like depression and wrong beliefs). It seems that MI can be helpful in two first methods, and for eliminating the psychological distress, one can get use of CBGT. References Aljasem, L. I., Peyrot, M., Wissow, L., & Rubin, R. R. (2001). The impact of barriers and self-efficacy on self-care behaviors in type 2 diabetes. The Diabetes Educator, 27, Bosy-Westphal, A., Geisler, C., Onur, S., Korth, O., Selberg, O., Schrezenmeir, J., & Muller, M. J. (2005). Value of body fat mass vs. anthropometric obesity indices in the assessment of metabolic risk factors. Int. J. Obes. (Lond). Gonder-Frederick, L., Cox, D. J., & Clarke, W. L. (2002). Diabetes. In A. J. Christensen and M. H. Antoni (Eds.), chronic physical disorders: Behavioral medicine s perspective (pp ). Oxford: Blackwell Publishers. Hampson, S., Glasgow, R., & Toobert, D. (1990). Personal models of diabetes and their relations to self-care activities. Health Psychology, 9,

5 1584 Hamid Pourisharif et al. / Procedia Social and Behavioral Sciences 5 (2010) Hoff, A. L., Wagner, J. L., Mullins, L. L., & Chaney, J. M. (2003). Behavioral management of type 2 diabetes. In L. M. Cohen, D. E. McChargue, and F. L. Collins, Jr. (Eds.), The health psychology handbook: Practical issues for the behavioral medicine specialist (pp ). Thousand Oaks, CA: Sage Publications. Katon, W., Simon, G., Von Korff, M., Ludman, E., Ciechanowski, P., Walker, E., et al. (2004). Behavioral and clinical factors associated with depression among individuals with diabetes. Diabetes Care, 27, Larsen, M. L., Horder, M., & Mogensen, E. F. (1990). Effect of long-term monitoring of glycosylated hemoglobin levels in insulin-dependent diabetes mellitus. N. Engl. J. Med., 323, 15, Larijani, B., Zahedi, F., & Aghakhani, S. (2003). Epidemiology of Diabetes Mellitus in Iran. Shiraz E-Medical Journal, 4, 4. Miller, W. R. (1983). Motivational interviewing with problem drinkers. Behavioral Psychotherapy, 11, Miller, W. R., & Rollnick, S. R. (1991). Motivational interviewing: preparing people to change behavior. New York: Guilford Press. Miller, W. R., & Rollnick, S. (2002). Motivational interviewing: Preparing people for change behavior. New York: Guilford Press. Ott, J., Greening, L., Palardy, N., & Holderby, A. (2000). Self-efficacy as a mediator variable for adolescents adherence to treatment for insulindependent diabetes mellitus. Children s Health Care, 29, Poursharifi, H. (2007). The effectiveness of motivational interviewing in improving health outcomes in adults with type 2 diabetes. Unpublished Ph.D. s thesis. University of Tehran, Iran. Rubak, S., Sandbaek, A., Lauritzen, T., & Christensen. B. (2005). Motivational interviewing: a systematic review and meta-analysis. Br. J. Gen. Pract., 55, 513, Rollnick, S. R., Heather, N., & Bell, A. (1992). Negotiating behavior change in medical settings: the development of brief motivational interviewing. J. Ment. Health.,1, Silventoinen, K., Sans, S., Tolonen, H., Monterde, D., Kulasmaa, K., Kesteloot, H., & Tuomilehto, J. (2004). Trends in obesity and energy supply in the WHO MONICA Project. Int. J. Obes. Relat. Metab. Disord., 28, Smith, D. E., DiLillo, V., Bursac, Z., Gore, S. A., & Greene, P. G. (2007). Motivational Interviewing Improves Weight Loss in Women With Type 2 Diabetes. Diabetes Care, 30, 5, Smith, D. E., Heckemeyer, C. M, Kratt, P. P., & Mason, D. A. (1997). Motivational interviewing to improve adherence to a behavioral weightcontrol program for older obese women with NIDDM. Diabetes Care, 1, Snoek, F. J., Nicols, C. W., Ven, V. D., & Lubach, C. (1999). Cognitive Behavioral Group Training for Poorly Controlled Type 1 Diabetes Patients: A Psychoeducational Approach. Diabetes Spectrum, 12, 3, 147. Snoek, F. J., Ven, N., Lubach, C. H., Chatrou, M., Ader, H. J., Heine, R. J., & Jacobson, A. M. (2001). Effects of cognitive behavioral group training (CBGT) in adult patients with poorly controlled insulin-dependent (type 1) diabetes: a pilot study. Patient Education and Counseling. 45, Svendsen, O. L. (2003). Should measurement of body composition influence therapy for obesity? Acta. Diabe., 40, 1, Tuckett, D., Boulton, M., Olsen, C., & Williams, A. (1985). Meetings between experts: an approach to sharing ideas in medical consultations. London: Tavistock. Wallace, P., Cutler, S., & Haines, A. (1988). Randomized controlled trial of general practitioner intervention in patients with excessive alcohol consumption. B. M. J., 297, Welschen, L. M., Oppen, P., Dekker, J. M., Bouter, L. M., Stalman, W. A., & Nijpels, G. (2007). The effectiveness of adding cognitive behavioral therapy aimed at changing lifestyle to managed diabetes care for patient with type 2 diabetes: design of a randomized controlled trial. BMC Public Health, 7, 74. Wild, S., Roglic, G., Green, A., Sicree, R., & King, H. (2004). Global prevalence of diabetes: estimates for the year 2000 and projections for Diabetes Care, 27, Williams, K. E., & Bond, M. J. (2002). The roles of self-efficacy, outcome expectancies and social support in the self-care behaviors of diabetics. Psychology, Health, and Medicine, 7, World Health Organization. (1985). Diabetes Mellitus: Report of a WHO Study Group. Technical Report Series No 727. Geneva: World Health Organization.